2. Spine and Spinal Cord Trauma

3. Objectives of Learning
Describe the basic spinal anatomy and physiology
Evaluate a patient with suspected spinal injury
Identify the common types of spinal injuries and their X-ray features.
Appropriately manage the spinal-injured patient during the first hour from injury.
Determine the appropriate disposition of the patient with spine trauma.

4. Introduction
Vertebral column injury, with or without neurological deficits, must always be sought and excluded in a patient with
Multiple trauma.
Any injury above the clavicle
Spine injury
Cervical spine 55%
Thoracic spine 15%
Thoracolumbar junction 15%
Lumboscaral spine 15%

5. Beware
Excessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome

6. Introduction
As long as the patient’s spine is protected, evaluation of the spine and exclusion of spine injury may be safely deferred, especially in the presence of systemic instability.
Every patient with spine injury should be log-rolled every 2 hours, while maintaining the integrity of the spine, to reduce the risk of decubitus ulcer formation.

7. Log rolling

8. Anatomy & Physiology The spinal column
The spinal column consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae as well as the sacrum and the coccyx.
For many reasons, the cervical spine is most vulnerable to injury
The thoracolumbar junction is a fulcrum between the inflexible thoracic region and the stronger lumbar levels. This makes it more vulnerable to injury, with 15% of all spinal injuries occurring in this region.

9. Spinal Cord Anatomy Spinal cord ends at L1
Three tracts can be readily assessed clinically.
The corticospinal tract
The spinothalamic Tract
The posterior columns
If there is no demonstrable sensory or motor function below a certain level, this is referred to as a complete spinal cord injury.
If any motor or sensory function remains, this is an incomplete injury and the prognosis for recovery is significantly better.
Sparing of sensation in the perianal region (sacral sparing) may be the only sign of residual function.

11. Sensory Examination
A dermatome is the area of skin innervated by the sensory axons within a particular segmental nerve root. They are important to determine level of injury
The key sensory points are
C-5----Area over the deltoid
C-6----Thumb
C Middle finger
C Little finger
T Nipple
T Xiphisternum
T Umbilicus
T Symphysis
L Medial aspect of the leg
L Space between the first and second toes
S Lateral border of the foot
S Ischial tuberosity area
S Perianal region

12. Myotomes The important key muscle (s) are.
C Deltoid
C Wrist extensors
C Elbow extensors
C Finger flexors to the middle finger
T Smalll finger abductors
L Hip flexors
L Knee extensors
L Ankle dorsiflexors
L Long toe extensors
S Ankle plantar flexors
For the sake of simplicity, certain muscles or muscle groups are identified as representing a single spinal nerve segment.
In addition to bilateral testing of these muscles, the external anal sphincter should be tested by digital examination.

13. Nerurogenic Shock vs Spinal Shock
Neurogenic shock results from impairment of the descending sympathetic pathways in the spinal cord resulting in loss of vasomotor tone and loss of sympathetic innervation to the heart The result is
Hypotension
Bradycardic

14. Management of Nerurogenic Shock
The blood pressure can often be restored by the judicious use of vasopressors, but adequate perfusuon may be maintained without normalizing the blood pressure.
Atropine may be used to counteract hemodynamically significant bradycardia.

15. Spinal Shock
This refers to the flaccidity and loss of reflexes seen after spinal cord injury. The “Shock” to the injured cord may make it appear completely functionless, although all areas are not necessarily destroyed. The duration of this state is variable.

16. Effect on other Organ Systems
Hypoventilation due to the paralysis of,
Intercostal muscles
Diaphragm
The inability to perceive pain may mask a potentially serious injury elsewhere in the body, such as the usual signs of an acute abdomen

17. Classifications of Spinal cord Injuries
Level
Determination of the level of injury on both sides is important.
Injury above the T-1 level quadriplegia
Injury Below the T-1 level paraplegia
Apart from the initial management to stabilize the bony injury, all subsequent descriptions of the level of injury are based on the neurologic level.

18. Severity of the Neurologic Deficit
Incomplete paraplegia
Complete paraplegia
Incomplete quadriplegia
Complete quadriplegia
Signs of incomplete injury may include:
Any sensation ( including position sense) or voluntary movement in the lower extremities.
Sacral sparing

19. Morphology Spinal injuries can be described as,
Fractures
Fracture dislocations
SCIWORA
Penetrating injuries
All injuries can stable or unstable
All patients with x-ray evidence of injury and all those with neurologic deficits should be considered to have an unstable spinal injury.

20. Specific Types of Spinal Injuries
Cervical spine injuries can result from
Axial loading
Flexion
Extension
Rotation
Lateral bending
Distraction

21. Specific Types of Spinal Injuries
Atlanto-occipital Dislocation
Atlas Fracture (C-1)
C-1 Rotary Subluxation
Axis (C-2) Fractures
Odontoid fracturres
Posterior element fractures of C-2
Fractures and Dislocation (C-3 through C-7)

22. Specific Types of Spinal Injuries
Thoracic Spine Fractured ( T-1 Through T-10)
Thoracolumbar Junction Fractures ( T-11 through L-1)
Lumbar Fractures
Penetrating Injuries

23. X-Ray evaluation Cervical Spine
A lateral cervical spine film should be obtained, when indicated, soon after life threatening problems are identified and controlled.
Swimmer’s view
Open-mouth odontoid view / Oblique view of the odontoid process

24. X-Ray evaluation
Thoracic and lumbar spine
A.P films
CT Scanning

25. General Management Immobilization Intravenous fluids Medications
Remember to immobilize until c – spine injury is excluded
Intravenous fluids
Patients with hypovolemia may not become tachycardiac (may be bradycardiac)
Medications
In North America methyprednisolone is given
Transfer

26. Spinal stability

27. Guidelines for screening patients with suspected Injury
The presence of paraplegia or quadriplegia is presumptive evidence of spinal instability
Patients who are awake, alert, sober, and neurologically normal, and have no neck pain are extremely unlikely to have an acute c-spine fracture / subluxation.
Patients who are awake and alert, are neurologically normal, but do have neck pain should undergo lateral, AP, and open-mouth x-rays of the c-spine.

28. Guidelines for screening patients with suspected Injury
Patients who are comatose, have an altered level of consciousness, or are too young to describe their symptoms should at least have a lateral and AP c-spine x-ray
When in doubt, leave the collar on
Backboards
Never force the neck

29. Guidelines for screening patients with suspected Injury
Assess the c-spine film for
Bony deformity
Fracture of the vertebral body or processes
Loss of alignment of the posterior aspect of the vertebral bodies (anterior extent of the vertebral canal
Increased distances between the spinous processes at one level
Narrowing of the vertebral canal
Increased prevertebral soft-tissue space

30. ?

31. Summary
Attend to life-threatening injuries, minimizing any movement of the spinal column
Establish and maintain proper immobilization of the patient until vertebral fractures or spinal cord injuries have been excluded
Obtain a lateral c-spine x-ray, when indicated, as soon as life-threatening injuries are controlled
Document the patient’s history and physical examination so as to establish a baseline for any changes in the patient’s neurologic status.

32. Summary
Obtain early consultation with a neurosurgeon and /or an orthopedic surgeon whenever a spinal injury is suspected or detected.
Transfer patients with vertebral fractures or spinal cord injury to a definitive-care facility